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Among patients with spondylolisthesis and lumbar spinal stenosis, laminectomy with fusion was associated with modestly greater improvement in physical health–related quality of life than laminectomy alone but not with significantly greater reduction in disability related to back pain. The increased use of the lumbar spinal fusion procedure in the United States, along with the wide variation in practice, is attracting interest from multiple stakeholders, including patients, physicians, payers, and policymakers. In a report published in 2014, spinal fusion (465,000 hospital-based procedures in 2011) accounted for the highest aggregate hospital costs ($12.8 billion in 2011) of any surgical procedure performed in U.S. hospitals. 1 The randomized, controlled Spine Patient Outcomes Research Trial (SPORT) showed that surgery was superior to nonoperative care for the management of lumbar degenerative spondylolisthesis. 2 In SPORT, most patients in the surgical group were treated by means . . .

Various factors related to predict surgical success were studied; however, a standard cut-off point for the Pain Sensitivity Questionnaire (PSQ) measure has not yet been established for a favorable surgical outcome for lumbar disc herniation (LDH). This study was to find the optimal cut-off point on the PSQ to distinguish surgical success in patients with LDH. A total of 154 patients with LDH consecutively referred to our clinic were enrolled into this prospective study between February 2011 and January 2014. All participants completed the PSQ. Patients completed the Oswestry Disability Index (ODI) score before surgery, and at 2 years after surgery. Surgical success was defined as a 13-point improvement from the baseline ODI scores. The cut-off value for PSQ was determined by the receiver-operating characteristic curve (ROC). The mean age of patients was 49.3±9.6 years, and there were 80 women. The mean time for follow-up assessment was 31±5 months (range 24-35). Post-surgical success was 79.9% (n = 123) at 2 years follow up. The mean score for the total PSQ, PSQ-minor, and PSQ-moderate were 6.0 (SD = 1.6), 5.4 (SD = 1.9) and 6.5 (SD = 1.7), respectively. Total PSQ score was also significantly correlated with the total scores of the ODI. The optimal total PSQ cut-off point was determined as > 5.2 to predict surgical success in LDH patients, with 80.0% sensitivity and 75.6% specificity (AUC-0.814, 95% CI 0.703-0.926). This study showed that the PSQ could be considered a parameter for predicting surgical success in patients with LDH, and can be useful in clinical practice.

PurposeThe purpose of this systematic review and meta-analysis was to compare the cervical sagittal parameters between patients with cervical spine disorder and asymptomatic controls.MethodsTwo independent authors systematically searched online databases including Pubmed, Scopus, Cochrane library, and Web of Science up to June 2020. Cervical sagittal balance parameters, such as T1 slope, cervical SVA (cSVA), and spine cranial angle (SCA), were compared between the cervical spine in healthy, symptomatic, and pre-operative participants. Where possible, we pooled data using random-effects meta-analysis, by CMA software. Heterogeneity and publication bias were assessed using the I-squared statistic and funnel plots, respectively.ResultsA total of 102 studies, comprising 13,802 cases (52.7% female), were included in this meta-analysis. We used the Newcastle–Ottawa Scale (NOS) to evaluate the quality of studies included in this review. Funnel plot and Begg’s test did not indicate obvious publication bias. The pooled analysis reveals that the mean (SD) values were: T1 slope (degree), 24.5 (0.98), 25.7 (0.99), 25.4 (0.34); cSVA (mm), 18.7 (1.76), 22.7 (0.66), 22.4 (0.68) for healthy population, symptomatic, and pre-operative assessment, respectively. The mean value of the SCA (degree) was 79.5 (3.55) and 75.6 (10.3) for healthy and symptomatic groups, respectively. Statistical differences were observed between the groups (all P values < 0.001).ConclusionThe findings showed that the T1 slope and the cSVA were significantly lower among patients with cervical spine disorder compared to controls and higher for the SCA. Further well-conducted studies are needed to complement our findings.

•Thirteen studies (92 patients) used a transnasal approach.•The remaining thirteen studies (1238 patients) performed a transoral approach.•Transoral odontoidectomy exhibited 90.0% neurologic improvement and 0.9% worsening.•Transnasal odontoidectomy showed 94.0% neurologic improvement and 0.0% worsening.•Transoral approach had a significantly higher rate of postoperative tracheostomy. The craniovertebral junction (CVJ) is a complex region of the spine with unique anatomical and functional relationships. To alleviate symptoms associated with pathological processes involving the odontoid process, decompression is often required, including odontoidectomy. Accurate knowledge of the complication rates following the transoral and transnasal techniques is essential for both patients and surgeons. We conducted MEDLINE, Scopus and Web of Science database searches for studies reporting complications associated with the transoral and transnasal techniques for odontoidectomy. Case series presenting data for less than three patients were excluded. Rates of complication and clinical outcomes were calculated and subsequently analyzed using a fixed-effects model to assess statistical significance. Of 1288 articles retrieved from MEDLINE, Scopus, and Web of Science, twenty-six met inclusion criteria. Transoral and transnasal procedures resulted in the following respective complication rates: arterial injury 1.9% and 0.0%, intraoperative CSF leak 0.3% and 30.0%, postoperative CSF leak 0.8% and 5.2%, 30-day mortality 2.9% and 4.4%, medical complications 13.9% and 28.6%, meningitis 1.0% and 4.0%, pharyngeal wound dehiscence 1.7% (transnasal not reported), pneumonia 10.3% (transnasal not reported), prolonged or re-intubation 5.6% and 6.0%, reoperation 2.5% and 5.1%, sepsis 1.9% and 7.7%, tracheostomy 10.8% and 3.4%, velopharyngeal insufficiency 3.3% and 6.4% and wound infection 3.3% and 1.9%. None of these differences were statistically significant, except for postoperative tracheostomy, which was significantly higher after transoral odontoidectomy 8.4% (95% CI 4.9% −11.9%) compared to transnasal odontoidectomy 0.8% (95% CI −1.0% −2.9%). Neurologic outcome was improved in 90.0% and worse in 0.9% of patients after transoral compared to 94.0% and 0.0% after transnasal odontoidectomy (p=0.30). This work presents a systematic review of complications reported for transoral or transnasal odontoidectomy across a heterogeneous group of surgeons and patients. Due to inconsistent reporting, statistical significance was only achieved for postoperative tracheostomy, which was significantly higher in the transoral group. This investigation sets the framework for further discussions regarding odontoidectomy approach options and their associated complications during the informed consent process.

PurposeTo explore the effectiveness and advantage of three-dimensional (3D)-printed navigation templates (3DPN-template) assisted in cervical spine fusion (CSF) surgery as compared to conventional surgery.MethodsAn electronic literature search in PubMed, Scopus, Web of Science, and Cochrane was conducted for studies of 3DPN-templates in CSF up to May 2020. Outcome measures as the accuracy rate, operation time, intra-operative blood loss, and fluoroscopy used, associated with CSF were extracted. Mean difference based on changes was quantified using Hedges’ g.ResultsFrom 4414 potentially relevant studies, 61 full-text publications were screened. Thirteen studies comprising 330 cases with 1323 screw placements were eligible for inclusion. For template group, pooled estimates were as follows: 97.3% accuracy rate for screw placement, 144.7 min for operating time, 273.6 ml for blood loss, and 3.2 min for fluoroscopic times. A significantly positive difference was observed between the template group compared to control group in terms of accuracy rate of screw placement (Z = 5.3), operation time (Z = 2.41), intra-operative blood loss (Z = 2.64), and fluoroscopic times (Z = 3.64) (all, P value < 0.0001). Risk of bias for studies under review was assessed using the Newcastle–Ottawa Scale (NOS), and 11 studies were found as having high quality. Overall, funnel plot and Begg’s test did not indicate obvious publication bias.ConclusionThe 3D-printed navigation template in the cervical surgery can improve accuracy of pedicle screw placement and consequently improve outcomes. In future, multi-center efforts are needed to validate the relationships found in this review.

Artificial neural networks (ANNs) have been used in a wide variety of real-world applications and it emerges as a promising field across various branches of medicine. This review aims to identify the role of ANNs in spinal diseases. Literature were searched from electronic databases of Scopus and Medline from 1993 to 2020 with English publications reported on the application of ANNs in spinal diseases. The search strategy was set as the combinations of the following keywords: “artificial neural networks,” “spine,” “back pain,” “prognosis,” “grading,” “classification,” “prediction,” “segmentation,” “biomechanics,” “deep learning,” and “imaging.” The main findings of the included studies were summarized, with an emphasis on the recent advances in spinal diseases and its application in the diagnostic and prognostic procedures. According to the search strategy, a set of 3,653 articles were retrieved from Medline and Scopus databases. After careful evaluation of the abstracts, the full texts of 89 eligible papers were further examined, of which 79 articles satisfied the inclusion criteria of this review. Our review indicates several applications of ANNs in the management of spinal diseases including (1) diagnosis and assessment of spinal disease progression in the patients with low back pain, perioperative complications, and readmission rate following spine surgery; (2) enhancement of the clinically relevant information extracted from radiographic images to predict Pfirrmann grades, Modic changes, and spinal stenosis grades on magnetic resonance images automatically; (3) prediction of outcomes in lumbar spinal stenosis, lumbar disc herniation and patient-reported outcomes in lumbar fusion surgery, and preoperative planning and intraoperative assistance; and (4) its application in the biomechanical assessment of spinal diseases. The evidence suggests that ANNs can be successfully used for optimizing the diagnosis, prognosis and outcome prediction in spinal diseases. Therefore, incorporation of ANNs into spine clinical practice may improve clinical decision making.

Abstract BACKGROUND Deformity reconstruction surgery has been shown to improve quality of life (QOL) in cases of adult spinal deformity (ASD) but is associated with significant morbidity. OBJECTIVE To create a preoperative predictive nomogram to help risk-stratify patients and determine which would likely benefit from corrective surgery for ASD as measured by patient-reported health-related quality of life (HRQoL). METHODS All patients aged 25-yr and older with radiographic evidence of ASD and QOL data that underwent thoracolumbar fusion between 2008 and 2014 were identified. Demographic and clinical parameters were obtained. The EuroQol 5 dimensions questionnaire (EQ-5D) was used to measure HRQoL preoperatively and at 12-mo postoperative follow-up. Logistic regression of preoperative variables was used to create the prognostic nomogram. RESULTS Our sample included data from 191 patients. Fifty-one percent of patients experienced clinically relevant postoperative improvement in HRQoL. Seven variables were included in the final model: preoperative EQ-5D score, sex, preoperative diagnosis (degenerative, idiopathic, or iatrogenic), previous spinal surgical history, obesity, and a sex-by-obesity interaction term. Preoperative EQ-5D score independently predicted the outcome. Sex interacted with obesity: obese men were at disproportionately higher odds of improving than nonobese men, but obesity did not affect odds of the outcome among women. Model discrimination was good, with an optimism-adjusted c-statistic of 0.739. CONCLUSION The predictive nomogram that we developed using these data can improve preoperative risk counseling and patient selection for deformity correction surgery.

Does the Finneson-Cooper score reflect the true value of predicting surgical success before discectomy? The aim of this study was to identify reliable predictors for surgical success two year after surgery for patients with LDH. Prospective analysis of 154 patients with LDH who underwent single-level lumbar discectomy was performed. Pre- and post-surgical success was assessed by the Oswestry Disability Index (ODI) over a 2-year period. The Finneson-Cooper score also was used for evaluation of the clinical results. Using the ODI, surgical success was defined as a 30% (or more) improvement on the ODI score from the baseline. The ODI was considered the gold standard in this study. Finally, the sensitivity, specificity, and positive and negative predictive power of the Finneson-Cooper score in predicting surgical success were calculated. The mean age of the patients was 49.6 (SD = 9.3) years and 47.4% were male. Significant improvement from the pre- to post-operative ODI scores was observed (P < 0.001). Post-surgical success was 76.0% (n = 117). The patients' rating on surgical success assessments by the ODI discriminated well between sub-groups of patients who differed with respect to the Finneson-Cooper score. Regarding patients' surgical success, the sensitivity, specificity, and accuracy of the Finneson-Cooper ratings correlated with success rate. The findings indicated that the Finneson-Cooper score was reflective of surgical success before discectomy.

Study design Systematic review and meta-analysis. Aim The purpose of this study was to compare the safety and accuracy of the C2 pedicle versus C2 pars screws placement and free-hand technique versus navigation for upper cervical fusion patients. Methods Databases searched included PubMed, Scopus, Web of Science, and Cochrane Library to identify all papers published up to April 2020 that have evaluated C2 pedicle/pars screws placement accuracy. Two authors individually screened the literature according to the inclusion and exclusion criteria. The accuracy rates associated with C2 pedicle/pars were extracted. The pooled accuracy rate estimated was performed by the CMA software. A funnel plot based on accuracy rate estimate was used to evaluate publication bias. Results From 1123 potentially relevant studies, 142 full-text publications were screened. We analyzed data from 79 studies involving 4431 patients with 6026 C2 pedicle or pars screw placement. We used the Newcastle-Ottawa Scale (NOS) to evaluate the quality of studies included in this review. Overall, funnel plot and Begg’s test did not indicate obvious publication bias. The pooled analysis reveals that the accuracy rates were 93.8% for C2 pedicle screw free-hand, 93.7% for pars screw free-hand, 92.2% for navigated C2 pedicle screw, and 86.2% for navigated C2 pars screw (all, P value < 0.001). No statistically significant differences were observed between the accuracy of placement C2 pedicle versus C2 pars screws with the free-hand technique and the free-hand C2 pedicle group versus the navigated C2 pedicle group (all, P value > 0.05). Conclusion Overall, there was no difference in the safety and accuracy between the free-hand and navigated techniques. Further well-conducted studies with detailed stratification are needed to complement our findings.

Retrospective Cohort. Tandem spinal stenosis (TSS) can present similarly to cervical myelopathy, but often has a worse prognosis. Few studies have investigated outcomes and compared treatment approaches for patients with TSS. We sought to determine the impact of cervical spine surgery on cervical and lumbar spine symptoms in patients with symptomatic tandem spinal stenosis. 84 patients with TSS were identified over 5 years. 48 underwent cervical spine surgery alone, 20 underwent both cervical and lumbar spine surgery, and 16 received conservative treatment alone (conservative cohort). Quality of life (QOL) measures included the Visual Analogue Scale (VAS) for arm, neck, and back pain, and EuroQOL-5 Dimensions (EQ-5D). QOL data were acquired at baseline (pre-operative) and 1 year postoperatively via an institutional prospectively collected database. Both surgical cohorts showed significant (p < 0.01) pre- to postoperative improvement for VAS neck and arm scores at 1-year post-op and significantly (p < 0.01) greater improvements than the conservative cohort. In addition, the cohort undergoing cervical spine surgery alone experienced significant improvement in the EQ-5D score whereas those undergoing both cervical and lumbar spine surgery did not. Cervical spine surgery with or without follow-up lumbar spine surgery significantly improves neck pain in patients with TSS. In contrast, cervical spine surgery in these patients does not improve lumbar symptoms. Lumbar surgery also did not improve low back pain or quality of life. Future prospective studies are necessary to examine the impact of lumbar decompression alone on cervical spine symptoms in patients with TSS.